Why has naloxone been kept from those who need it?

Since Pulp Fiction hit the big screen in 1994 it’s been public knowledge that a drug overdose can be reversed. Dramatic as it was, Tarantino captured the abrupt rise of Mia (played by Uma Thurman) from her unconsciousness state, wonderfully. With the needle having been driven through the woman’s chest bone she takes one massive breath as if coming to the top of a body of water.

The medical fraternity have been using the drug naloxone (also known by its retail name Narcan) for a lot longer than that. First developed by the Japanese pharmaceutical company Daiichi Sankyo in the 1960s, the drug has been available to hospital staff since the early 1980s. Its use in emergency departments became both well-known and widespread, certainly in the West, and by the late 80s – after some debate – ambulance officers in Australia began to carry it as a matter of routine; a good thing given the number of lives that have been saved. Most notably, this was also when the door opened for GPs to become prescribers.

In my role of providing clean injecting equipment, I’ve seen more than a few overdoses. All of these, and indeed every overdose I’ve observed, has ended well. However, the number of people I know who have died in this way is probably getting close to fifty.

Perhaps that’s why in 2010 when I heard Dr Sarz Maxwell speak at a national conference in Melbourne about the work she was doing in Chicago, regarding drug users administering naloxone to their peers, I was dumbfounded. Not because it was possible – all of us in the drug and alcohol sector had known that for a long time – but because when she was asked how they got authorisation to do it, she said: We didn’t. Actually, we just went ahead without permission.

Call me naive but hearing of this in a country like the USA, where there is no coordinated needle exchange and an urgent need for uniform Good Samaritan laws so people are free of the fear of prosecution after remaining at the scene of an overdose, left me gobsmacked. I remember thinking, why couldn’t we do this in Australia? Why weren’t we doing it? Too many people had died already and we shouldn’t dally another day.

The following year, in November 2011 the Medical Observer published an article by Danny Rose. It appeared with the by-line: ‘Should Australia allow non-medical professionals to administer an antidote for heroin overdoses?’ The article points out that: ‘While supporters say there is little barrier to such programs being conducted in Australia, legislative change is needed to clarify protections both for those prescribing and administering the drug.’ And further into the piece: ‘…Good Samaritan laws in Australia lack consistency across the states and most exclude people under the influence … (something more than likely in an overdose situation) … from protection.’

Were these concerns part of the mix that stopped Australian harm reduction advocates (of which I am one) being as brave – even rebellious – as our counterparts in other parts of the world, some of whom live under far more authoritarian governments and punitive legislative frameworks. Or did we simply lack the gumption needed to do something that hadn’t yet been sanctioned. Was it the thought that the services we do run could lose government funding (a fear based in reality) that stopped us or, more generally, the status quo that injecting drug users are vile creatures who deserve nothing.

Despite knowing what the morally correct thing to do was, the sector proceeded with caution. A plan to distribute naloxone to a wider population was lobbied for in the ACT and on 16 December 2011 the Chief Minister of the Capital Territory launched a pilot program. This was a heartening sign. But despite there being merit in a systematic and sanctioned rollout, over the last eighteen months thousands of people have died. Others, it should be noted, although alive have suffered hypoxia: a lack of oxygen to the brain which causes permanent injury.

Naloxone is a pure opioid antagonist. It reverses the effects of both natural and synthetic (including semi-synthetic) opioids such as codeine, heroin, methadone, morphine, fentanyl and propoxyphene. Its record of safety is extraordinary. It has no side effects and no addictive qualities. Actually it is said to have no effect at all if consumed by someone who has not taken an opiate. Meanwhile the mortality and morbidity from heroin overdose has been increasing all over the world. In Australia the incidence of heroin overdose deaths increased from 1.3 per million in 1964 to 71.5 in 1997. By 2007 heroin-related deaths had been implicated in 9.4% of the total mortality in all persons aged fifteen to thirty-nine years in Australia.

These sorts of statistics are not unique. Differences are marked however in the way programs in other nations responded to the deaths. Some organised themselves with good supplies of naloxone and developed procedures to disseminate the drug. It wasn’t that they didn’t have to counter issues of negative public perception: people with the view that drug users should die live all over the globe. Hence, programs that tried, quite literally, to keep them alive, had an underground flavour; some, perhaps, less than others, but all – at least looking in from the outside – occurred from the –ground up. The programs in the nations under less pressure to hide their activities were more inclined to be evaluated.

Beginning in the mid-1990s the Italians had the first documented provision and training available for administration. They were followed by reports of underground programs in Chicago and San Francisco. As of 2005, Australian researches Paul Dietz and Simon Lenton found naloxone was being provided to potential overdose witnesses in Canada, Germany, Georgia, Russia, Spain, Norway, Afghanistan, China, Kazakhstan, Tajikistan and Vietnam

The ‘establishment’ in some jurisdictions also made moves to sure up programs. In January 2001, New Mexico became the first state in the US to encourage physicians to prescribe take-home naloxone to heroin-injecting patients. Augmenting this move, New Mexico’s governor, Gary Johnson, implemented legislation that released individuals and medical professionals involved in administering and prescribing naloxone from medical liability. Connecticut and New York followed with laws that established standards for heroin-overdose prevention and provided immunity from civil liability to non-health professionals by defining the use of naloxone as a first-aid or emergency treatment.

In 1995 the drug was rescheduled in Italy to ensure its availability over the counter. Still sold from the corner pharmacy, there have been no adverse reports – legal, health or otherwise – ever recorded in that country to date.

Indicative of our tardiness, Australia is only just beginning to grapple with the rise in deaths from prescribed medications, a point missing from the article mentioned earlier in the Medical Observer. Naloxone works to reverse all opiate overdoses, which means an overdose of prescribed painkillers such as the oxycodone group of medications – an important point given the rise in fatal overdoses from this family of drugs. Although it is difficult to get comprehensive data for all of Australia, deaths from pharmaceutical opiates currently surpass those from illicit drugs. Again, to cite Victoria, prescription painkillers contributed to 82.5% of the state’s fatal drug overdoses in 2012 while illicit drugs were found in just 35.7%. Deaths involving prescription drugs (304) exceeded those from road traffic accidents (282).

Following the investigation of an accidental death of a Melbourne man from prescribed medication in May 2012 Coroner Audrey Jamieson recommended the Department of Health implement a real-time prescription monitoring system. This would curb the practise of ‘doctor shopping’ and act as a reminder of the potency of these substances for doctors as well as patients. While no one wants to see pain being under-medicated there seems to be a general paucity of knowledge about the overdose properties of prescribed suppressants. Dangers should be relayed clearly and without fuss. But what stands out even more is why the antidote to an overdose hasn’t been offered as an option to people who might be taking the medication on a regular basis. Admittedly – something that changed in 2012 when naloxone became available through the pharmaceutical benefits scheme (PBS) – naloxone, priced during the 1990s and 2000s at approximately $50 a prescription, was expensive. But why not give a patient the respect of knowing that it was available, and, if it had been talked about in the process of such a consultation then awareness of the possible risk involved in taking these pain-relieving drugs would have been far more widespread.

So why is this? Why have we been dragging our feet in regard to not only talking about naloxone more generally but putting it in the hands of those likely to either suffer an overdose or witness one? Much of the reason lies in the depth and reach of the stigma attached to drug users. Stereotypes promulgated by both the media and successive governments have resulted in a startling complicity by all. Decisions effecting drug users – including the resistance to disseminate this lifesaving drug – means not only have we fallen behind in our effort to reduce harm, we have literally been negligent in our responsibility.

Of course, to the general public the contention that society should be held accountable, even partly, for any of these deaths, may sound laughable. But to those who have lost loved ones this is no laughing matter. Rage is more the response that has jettisoned from friends and family in the USA when they realise naloxone has been around for years and that, like a conspiracy to allow people who take drugs to die, it has been, not so much legally but through lack of education, systematically withheld. Given my belief that most people working in the field of health have honourable intentions, the answer to this lies in something woven so deeply within us that while we can name it – even describe it – stigma, when at play, can still manage to prevail.

In 2011 AIVL (Australian Injecting and Illicit Drug Users League) published a report called ‘Why Wouldn’t I Discriminate Against All of Them? A Report on Stigma and Discrimination towards the Injecting Drug User Community’. It notes that:

The legislative and policy framework that defines community norms and the legal sanctions that support those norms and expectations have developed over centuries. They are so deeply a part of the fabric of our society that most people do not think about how or why particular customs and laws exist: they simply understand the reality of them.

According to the authors, the process of ‘discrimination’ began as the industrial revolution got underway in the late 18th and early 19th centuries. It was the period in which individuals became units of labour. Theorists such as Foucault said it was a time when ‘sovereign power’ became ‘disciplinary power’. Rather than control being meted out in the form of physical coercion by the sovereign it ran more laterally through communities in the insidious form of surveillance and the development of ‘normalisation’. The transition to ‘disciplinary power’ led to the appearance of a range of institutions that had not previously existed – prisons, mental hospitals and so on. For the first time people were categorised and labelled through statistics of deviance: suicide, prostitution, drunkenness, vagrancy, madness, crime were defined by numerical analysis. Parameters were drawn around acceptability and the first signs of exclusion arose. As people shifted during this period into cities in unprecedented numbers, competition between individuals emerged. Those pursuing wealth and status strove to tighten the agenda. Association with those who deviated was akin to failure. Those outside the parameters were slowly but methodically excluded. The notion of the ‘undeserving’ was born and, although exclusionary boundaries have shifted over the years, what seems to have remained throughout is the existence of marginalisation, for which the most common factors are ethnicity and low socio-economic circumstances. Drugs became an easy way to exclude these groups, to mark them by making what they did illegal, which not only led to disenfranchisement but to removal through imprisonment.

It is well documented that many of the initial attempts to control opium in Australia were motivated by racism. In 1899 the Victorian Premier’s Drug Advisory Council named three main ‘classes’ of opium users – middle-class, middle-aged women who took the drug for menstrual pain or to alleviate the symptoms of depression; doctors, nurses and other health professionals who used the drug as a strategy for coping with the stress of their work; and Chinese migrants, amongst whom, it was said, smoked the drug for the purpose of recreation. Only the smoking of opium practised by the Chinese (Anglos were more inclined to sip tinctures of the drug) was prohibited. Scores of Chinese were locked up as a result of the smoking grade drug having been restricted. By 1905 laws prohibiting the import and use of smoking-grade opium were passed and yet by the 1930s Australia had developed the world’s highest per capita rate of heroin consumption.

Similar laws incarcerating large numbers of Chinese were being passed in California and, as for a number of other issues, Australia was looking to the northern hemisphere for direction. In 1971 Richard Nixon famously declared a ‘war on drugs’ and this tough talk, which turned Nixon’s poor polling around, resonated with politicians here. Ironically, albeit, not so well known, Nixon understood that treatment was more important than law enforcement and, while his funding strategy reflected this knowledge, his hard-hitting rhetoric on drugs set a new standard of electioneering. A long line of successive US candidates followed his example and administrations who did not understand the importance of treatment began to shift money to back their hardline position. Steadily resources were pulled away from a health and social perspective and placed into a criminal justice response.

Australia’s first National Drug Strategy was drawn up in 1985 emphasising supply reduction, (law and order measures) demand reduction (education and prevention) and harm reduction (treatment and clean injecting equipment). Similarly, from Prime Minister to Prime Minister beginning with Bob Hawk, funds were shifted out of treatment and prevention and redirected into a legal and law enforcement reaction. No period more than John Howard’s points to the interwoven continued failure to both lower harm to people – including reducing the number of deaths – and achieve the goal of lowering the incidence of drug use. On 2 November 1997 Howard announced his $87.5 million ‘tough on drugs’ strategy. As we had already seen in the USA, this rhetoric came at a time when his opinion polls were at a record low and was intended to regain the electoral initiative.

‘Lives are at stake,‘ he said, ‘and this government means business.’ The hypocrisy was stunning. After killing off the widely supported ACT heroin trial, Howard’s government scrapped the drug education program run during the ALP’s term only to replace it with a similar campaign funded with money which had previously been allocated to drug research and treatment – around $7.6 million between 1993 and 1996. Consolidating the Coalition’s ‘law and order’ campaign, state governments were fully supportive. In NSW the Labor Party conveniently diverted public attention away from the causes of worsening living standards by creating scapegoats. The ideological onslaught against ‘youth gangs’ and Asian ‘drug lords’ followed. Blame was apportioned to drugs for increased unemployment rather than the reverse. This sort of conveniently misleading hyperbole led to an escalation in racism and a rise in the level of insecurity felt by the majority.

What becomes startlingly apparent is that parliamentarians win votes over hot topics while individuals are – usually through a combination of alienation and removal – stopped from having a voice.

In 2001, after high rates of death in Australia from overdose, I founded Overdose Awareness Day. It has become an international event marked in dozens of locations around the world. A small revolution; a day in which the judged can at least acknowledge themselves as deserving of dignity. Over the years, politicians such as Jenny Macklin and Mary Wooldridge, along with dignitaries such as Professor David Penington and Magistrate Jelena Popovic, have launched the day, after which people have shared stories of the untimely deaths of their children and siblings.

Many families, struggling with the complicated emotions of guilt and grief, are unable to talk openly about a death involving drug use. As for drug users, some have lost so many of their friends the suffering can be large and unwieldy. With very little recognition that they should grieve for their loss, given the deceased’s continued use of drugs, I felt that Overdose Awareness Day provided a small avenue by which to reinstate that basic right. Together with parents and siblings the throng of mourners swelled. In our first year I bought enough ribbon to make 500 lapel pins. Word got out and we had requests from other services and individuals. By the time the day arrived we had given out 6,000 ribbons.

Some will say that nobody can ever put a cost on what respect means to people. Dr Sarz Maxwell in her 2010 talk in Melbourne, flashed messages up on her power point presentation such as: ‘Dead heroin addicts are interesting. Saving heroin addicts is not.’ And, ‘Distributing naloxone… because dead addicts NEVER recover.’

What is mystifying when I reflect on this is why we (in the drug and alcohol sector) have been putting up barriers – to dispensing naloxone. It’s a big question given the drug has been available on prescription for over two decades. Compared to our counterparts in other nations, it strikes me that we have been particularly deferential to the organisations and institutions who govern us. Despite knowing our counterparts in other jurisdictions were going ahead, were challenging the status quo, we chose in almost every case, to sit on our hands.

Admittedly there have been two important shifts in the past eighteen months. The first, which I flagged earlier, and probably the most significant for practical reasons, is that instead of costing a prohibitive (to some) $36.80 for a script, the price of naloxone on the PBS is now $5.90. Secondly on 1 December 2012 the Australian Medical Association (AMA) endorsed the use of naloxone by peers and family members in order to save lives and reduce the number of permanent injuries that overdose could cause. AMA President Dr Steve Hambleton said, ‘The AMA’s Federal Council agreed, on the basis of evidence, that properly administered and supported naloxone distribution programs, involving suitable training, had the potential to save lives.’ However, neither detail has quelled a sense of regret in many of us who work in the harm reduction field.

The unveiling of our blind spot occurred over about an hour and a half at a symposium run by the Burnet Institute in Melbourne. Carrie Fowlie, from the Alcohol Tobacco and Other Drug Association (ATODA) in the ACT, was presenting initial outcomes of the pilot program, also mentioned previously. As we digested the news that all the impediments they thought existed, fell away, and the program went from being a ‘pilot’ to becoming ‘core business’ without official sanction, my manager and I were sideswiped. In the month leading up to this particular morning, four loved clients at our service had died from overdose and another death had taken the life of a young indigenous man who had shot up for the first time. Reeling, we promised even before Carrie’s speech was over, to proceed with our own program. We had the doctors, we had the knowledge and we had the clientele. There was nothing more we needed.

Other service providers in the audience will, most likely, wait no longer either. And on a positive note, word has it that something very comprehensive is to be rolled out across the state of Victoria in the near future – something that will surely follow in other states. This is a necessary move as naloxone is needed in rural areas as much as it is in metropolitan districts. And as always, a comprehensive change is far more preferable than anything on a piecemeal platform. However, none of this takes away from all that we have lost in the interim.

Overland is a not-for-profit magazine with a proud history of supporting writers, and publishing ideas and voices often excluded from other places.

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SJ Finn writes fiction that always has a thread of truth woven into it. The story ‘Infiltration’ has been created in that vein. Her short fiction has been widely published and received several awards. You can find her at www.sjfinn.com

Comments

Great article SJ. You’ve raised a number of issues that need further open, honest and deep discussion. While there’s still political and media capital to be gained from the great divide between what society sees as ‘acceptable’ and ‘unacceptable’ drug use we will continue to experience the divisive, stigmatised and discriminatory policies that dominate illicit drug policy in Australia. I think one of the most disappointing aspects in this debate us the lack of leadership within the harm reduction sector. There are few, AIVL being one, that is prepared to challenge the hypocrisy and political self interest that drives current illicit drug policy discussion. Why can’t we move on from the drug war language such as harm reduction ‘sending the wrong message’ and ‘putting up the white flag’ etc? Who and where are our harm reduction leaders? HD

Thanks Greg. It does seem that harm reduction advocates feel stuck between a rock and a hard place not knowing quite how to proceed. Sometimes I feel as if we have been filed down by the weight of capital that, as you so rightly say, exists in the media and political spheres. For example I’d like to see us – in some areas at least – test the laws rather than follow them. But, as I say in the essay, attracting attention may mean putting something else – given harm reduction’s misunderstood place in our community – at risk. AVIL, indeed, put together a stunning report re the issues.